The Needs of Incarcerated Pregnant Women: A Systematic Review of Literature

ABSTRACT Background: With increase in the number of female prisoners, it seems necessary to follow up the conditions of pregnant women in prison in order to identify their needs and provide healthcare and social services to improve their health accordingly. Therefore, a systematic review was conducted to examine the needs of incarcerated pregnant women. Methods: In this systematic review, we searched the databases including PubMed, Scopus, Web of Science, EMBASE, PsycINFO, and the Cochran Library. All studies including cross-sectional, retrospective, and prospective cohorts as well as case series, which addressed the needs and expectations of incarcerated pregnant women, were included in this review. Two reviewers independently evaluated the retrieved articles, the discrepancies were discussed, and a consensus was achieved. Results: 31 eligible studies consisting of 5435 incarcerated pregnant women were included in the review. The needs of incarcerated pregnant women comprised six general categories: healthcare needs including prenatal, labor, delivery, and postpartum services; educational needs on pregnancy, childbirth, and parenting; the support needs to be provided by government agencies, social workers, and doula services; the need for psychological counseling services; nutritional needs during pregnancy; and the needs related to the substance abuse management. Conclusion: The needs of incarcerated pregnant women included healthcare, educational, supportive, counseling, and nutritional needs as well as those related to the substance abuse management. Identifying these needs can be useful in developing accurate and appropriate policies and programs to promote the health status of this vulnerable group.


Introduction
With increase in the number of female prisoners all around the world, pregnancy in this population has also become an important concern. Many organizations do not provide statistical reports on pregnancies in prison, and most of them do not have a routine process for recording and collecting the data. 1 Published reports indicate that about three to four hundred women are pregnant at the beginning of their imprisonment in the US state and federal prisons. [2][3][4] Other reports show between six and ten percent of pregnancies are in the prison all around the world. 5 According to the last report in Iran, the number of female prisoners is on increase, accounting for 3.1 percent of the total prison population. The global growth rate of this population has increased from 7.2% in 2006 to 8.8% in 2014. 1 In the female prisoner population, pregnant women are identified as a high-risk and special group. 6 The consequences of pregnancy in prison indicate the need for these women to optimize and pay attention to their living conditions in prison. 2 Investigating the official UK government documents shows the special reproductive and psychosocial needs of pregnant prisoners. The personnel of prisons or hospital staff had subjected some of these women to some form of verbal, psychological, or physical violence during their stay in prison or during childbirth. Most of them, because of the lack of proper family or social relationships, needed support. Problems of being bound during labor and delivery processes added to their problems. Also after giving birth and returning to prison, they did not receive the required postpartum care, and more importantly, they were separated from their infant very soon. 7 World Health Organization in its "recommendations on antenatal care for a positive pregnancy experience" has highlighted that the needs of incarcerated pregnant women are not considered in the prisoner care program. 8 In Iran, also, despite the existence of health guidelines in the prison system, 9 no adequate attention is paid to the health of pregnant women. 10 These documents show that incarcerated pregnant women are vulnerable in the society, both inside the prison and after their release. In some ways, the needs of incarcerated pregnant women are not the same as those of other vulnerable women in a free society, because they have access to national and international clinical guidelines. 11 However, imprisonment impose unique restrictions on daily life plans, nutrition and diet, prenatal care, delivery, support, and contact with the newborn. 12 In a study on reproductive justice in the US prisons, it has been highlighted that for preventing further vulnerability of incarcerated pregnant women and meeting their health and fertility needs, prison policies and practices need to be improved and reformed In this study, it has also been emphasized that there are still many problems and deficiencies in relation to the pregnant women's health in prison It is noteworthy that the organizational facilities are not enough to deal with the pregnancy issues in prisons. Also, the needs of pregnant women have not been properly understood. 13 Examination of the existing documents for the care of pregnant women in Iran showed that Examination of the existing documents for the care of pregnant women in Iran showed that the health promotion of incarcerated pregnant women was not prioritized in healthcare planning. In a review of international guidelines on healthcare for pregnant women in prison, it has been emphasized that there are currently gaps in the healthcare guidelines in many aspects; for upgrading these guidelines and providing comprehensive and complete care programs, it seems necessary to identify and classify the needs of incarcerated pregnant women through conducting a systematic review on this vulnerable population needs. 14 This information gap has caused disciplinary organizations to fail to achieve the optimum level of care and not have the required efficiency. 15 The health care provided to imprisoned pregnant women is of considerable public health importance, 16 Alirezaei S, Latifnejad Roudsari R ijcbnm.sums.ac.ir and no systematic review has been found to address this salient issue. Because of the lack of data and the issues previously argued based on the relevant literature, the focus of the present review moved to an examination of the current worldwide situation in terms of healthcare needs for pregnant women in prison. Systematic reviews could identify, appraise, and summarize the results of all relevant studies over a health-related issue, so they would make the available evidence more accessible for program and policy development. 17 This review aimed to systematically summarize and critically evaluate the literature so that a clear understanding of the health needs is gained.

Methods
This study was performed based on the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist for systematic reviews. 18 An intensive and regular search of English articles was conducted in databases of PubMed, Scopus, Web of Science, EMBAS, PsycINFO, the Cochran Library as well as the reference lists of the retrieved articles through hand searching between 1984 and 2020. The keywords included: (Pregnancy OR "Pregnant Women" OR "Prenatal Care" OR "Antenatal Care" OR "Postpartum Care" OR Childbirth OR "Pregnancy Outcomes") AND ("Prisoners" [-Mesh] (Table 1).
All quantitative studies including crosssectional, retrospective and prospective cohort, model testing, as well as case series and survey, which addressed the needs and expectations of incarcerated pregnant women, were included in this review, letters to the editor, newspapers and newsletters, conference summaries, qualitative and experimental studies were the exclusion criteria. Unrelated and duplicate papers were also excluded from the review.
Two reviewers evaluated all the articles, and the data were based on a pre-designed table (Table 2). Data included the first author's name, year of publication, place of study, study design, sample size, types of needs cited in the results, and score of qualitative synthesis of articles. Any discrepancies between the reviewers were resolved through discussion until consensus was achieved.
The methodological quality of the papers was evaluated using the combined STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement (Table 3), which is a 22-item checklist that assesses the essential items of cross-sectional and observational studies. 18 It could also be applicable for case series, as any of the key elements in STROBE can be applied in this design. 19 The aim of the scoring method was to obtain an overall quality score for the retrieved    articles. For scoring, it was decided to have scores of 0: if the particular checklist item was not fulfilled, and a score of 1: if the particular checklist item was fulfilled. Maximum possible STROBE scores for observational studies were as follows: cohort=34, case-control=33, and cross-sectional=27. 20 Similar studies were used to determine the cut-off point. 21 Obtaining 75% of the total score and above, between 25% and 75%, and less than 25% were classified as good, average, and poor quality, respectively. 22, 23

Results
In this systematic review, initially, 6046 records were identified (6020 records identified through database searching and 26 additional records through other sources). 15 records were removed due to duplication. Thereafter, the records were screened based on the titles and abstracts, and 5960 articles were excluded. In addition, 12 records due to irrelevance, 10 articles due to being a conference abstract, and 4 articles due to being letter to editor were excluded. After reviewing the full text articles based on the inclusion and exclusion criteria for article selection, finally, 31 eligible articles were included in the qualitative assessment ( Figure 1).
The year of publication of the articles ranged from 1984 to 2018, and the sample size varied from four to 515 people in different studies.
The total sample size was 5435 incarcerated pregnant women. 24 studies were conducted in different states of the USA, five studies in the United Kingdom, 1 study in Australia, and one study in Germany (Table 2).
In the present study, 31 articles (9 crosssectional studies, 13 cohort studies, 6 case series, 1 correlational model testing, and 2  surveys) were reviewed. The quality of six studies was poor, 22 average, and three good. In these studies, the needs of pregnant women were categorized into six general categories of healthcare (13 studies), educational (6 studies), supportive (7 studies), counseling (2 studies), nutritional (3 studies), and substance abuse management (7 studies) types.

Healthcare Needs
The need for care was concentrated on prenatal care, the care provided during labor and delivery and postpartum, the care of HIVpositive pregnant women, and prevention of vertical transmission to the fetus. The needs for care expressed in studies by , 24 Siefert (2001), 25 Bell et al. (2004), 26 Cordero et al. (1991), 27 Cordero et al. (1992), 28 , Safyer (1995), 29 Terk et al. (1993) 30 include the need for in-prison prenatal care. Elton (1985) 31 points to the importance of early pregnancy care and Howard (2009) 32 points to the increasing number of such cares. Kyei-Aboagye (2000) 33 and Stauber (1984) 34

Educational Needs
Educational needs were discussed in relation to pregnancy classes, childbirth classes, classes for a doula, parenting classes, as well as family planning and safe sex counseling.
The educational needs mentioned in the studies of Dallaire (2017), 36 Carlson (2009) 37 and Ferszt (2008) 38 were about the concerns related to pregnancy. Rowles (2007) 39 and Carlson (2000) 40 considered the educational needs during childbirth, parenting skills, and infant care as important needs. On the other hand, Tapia and Vaughn (2010) 41 indicated the need of these women to education on postpartum pregnancy follow-up methods.

Supportive Needs
The review of the included studies showed that one neglected need of incarcerated pregnant women was support. The support needs were discussed in some areas including organization support, labor and delivery support, need for social workers, release from prison, and separation from their baby.
Regarding the support needs, Stauber (1984) 34 and Shlafer et al. (2015) 42 referred to the support of the prison authorities of pregnant prisoners.   43 and Inoue (2003) 44 discussed the need for pregnant women to have double support during labor and delivery. The need for a social worker is mentioned in Siefert (2001) 25 in prison and Martin (1997) 45 after release from prison. Caddle and Crisp (1997) 46 pointed to the mother prisoner's need for support during separation form her infant.

Counseling Needs
Psychological disorders, drug abuse, the stress of pregnancy and childbirth in prison, and most importantly, separation from the child are among the issues that indicate the need for counseling services to pregnant women. Promoting the health of pregnant women in prison, including mental health, is one of the needs mentioned in the study of Fogel (1993) 47

Need for Nutrition, Activity, and Rest
Nutritional needs, and also need to adequate activity and rest for pregnant women in prison, were also mentioned in the studies by Cordero et al. (1991), 28 Mertens (2001) 49 and Dallaire (2017). 36

Discussion
This was a systematic review to determine the needs of pregnant women in prisons. This review summarized the evidence from thirtyone studies. The results showed that the needs of incarcerated pregnant women consisted of six general categories of healthcare, educational, supportive, counseling, nutritional, and substance abuse management types.
Despite the efforts made, there are still many deficiencies in the field of pregnant women's health in prison. It is considered necessary to recognize and update the needs of this vulnerable group of women in order to provide comprehensive and complete care programs. 14 One of the needs of incarcerated pregnant women was healthcare. It has been reported that less attention to incarcerated pregnant women's needs has more costs for society. The reason is that it could be associated with adverse physical and psychological effects. 4 Some studies have shown the need for prenatal care models with a focus on specific healthcare needs of pregnant inmates, while there is limited information about different types of care models for this population. 16,54,55 The American College of Obstetricians and Gynecologists has emphasized that to meet the need for prenatal care in prisons, the care should be provided in accordance with the academic guidelines and should not be less than what is provided in the community. 56 However, evidence shows that health and wellbeing needs are not met in most prisons. 57 Another need of incarcerated pregnant women was need to education. It has been argued that education regarding pregnancy and parenting is one of the oldest and most detailed health promotion needs. 53 Some studies have shown that incarcerated pregnant women, particularly, need education as they usually experience high-risk and complex pregnancies due to their history, such as drug and alcohol abuse, high-risk sexual behaviors, and related diseases. 3,58,59 Consistent with our findings, the results of a systematic review showed that a safe and secure prison environment could be a good place to teach parenting skills to pregnant women. 12 Also, it was highlighted by another review article that through educating during pregnancy, it would be possible to change the behaviors and lifestyle of women in order to provide a positive attitude towards pregnancy and childbirth. 4 Supportive needs were another neglected need of incarcerated pregnant women in this review. It is obvious that pregnant women and their infants are among the population that need supportive community programs. 60 In line with our results, it was reported in a study that an early intervention framework using external support can have a significant supportive impact on pregnant women and their families. 61 Some studies suggested that the need for support is especially vital in pregnant women, particularly, financial support. In addition, the need for emotional support seems vital for pregnant women in prison due to being away from families and friends. Furthermore, social support could help incarcerated pregnant women to cope with the crisis of being jailed. [62][63][64][65] It has also been reported that many of these women have no contact with the outside world during pregnancy and childbirth and do not receive support from family or friends, so they need more supportive cares. 66 However, in one study in New South Wales, Australia, it was found that prisons did not provide the social and even emotional support needed. 51 It has been emphasized in a review article that one of the sources of support is adoption of organizational policies and laws that support pregnant women and lead to the establishment of reproductive justice for mothers and the protection of their infants and children in prison. 13 In another study which analyzed the Washington State's Residential Parenting Program for Pregnant Inmates, it was stressed that prison can provide a great opportunity to reach a vulnerable group of pregnant women and, through provision of the right health and social services, promote their health in prison IJCBNM January 2022; Vol 10, No 1 and their ability to participate in communitybased programs even after release. 58 Another need of incarcerated pregnant women was their need for counseling. Researchers attribute the need for counseling to the stressful and painful life of pregnant prisoners, which can have a devastating effect on their well-being and health. In addition, they believe that incarceration hinders the pregnant women's ability to adapt. 65,66 However, a survey of all US prisons with a 61 percent response rate found that there was no significant counseling program to address the mental health problems of pregnant inmates However, some prisons offer counseling programs for all female prisoners and particularly have special programs tailored to the needs of pregnant women. 67 It has been found that there is a lower rate of cases of psychosis and neurological disorders in pregnant prisoners receiving psychological counseling, so prison can become a place for treatment. As a result, screening, identifying and treating mental disorders can benefit many vulnerable mothers in this population. 49 Counseling and correcting high-risk behaviors can play a unique role in improving pregnancy outcomes, so that, according to a study (1993), women who spend more weeks in prison, while receiving more counseling services, had better pregnancy outcomes. 30 One of the most important and neglected needs of incarcerated pregnant women was poor nutrition during pregnancy. One study reported that women who received high quality foods during imprisonment experienced less maternal and fetal complications than others. 68 In another interventional study which investigated the effect of a nutrition-based program on incarcerated pregnant women, it was concluded that because of dietary changes during pregnancy, the criminal justice system could use this opportunity to develop a nutritional support program for vulnerable and disadvantaged groups. 36 Therefore, researchers have provided recommendations for improving the nutritional care of incarcerated pregnant women in accordance with the guidelines provided by the Academy of Nutrition and Dietetics. 36,69,70 In this way, the limited opportunity of imprisonment can be used to provide nutritional education to this population in order to have benefits beyond imprisonment. In another study which examined low birth weight (LBW) and fetal death rates for women incarcerated during pregnancy, it was concluded that the role of nutrition in promoting health and improving the consequences of pregnancy in female prisoners is very important basic principle. 50 A study which compared demographic features and substance use in pregnant and non-pregnant female inmates reported that it was important to identify the potential needs of these women in order to improve their conditions in prison and subsequently improve the outcome of pregnancy and childbirth. 53 In a narrative review, which focused on the international guidelines for incarcerated pregnant women, it is suggested that corrective facilities that care for these women should be based on standards of care and evidence-based methods to treat women with methadone or buprenorphine. It is also recommended that these centers should provide the necessary facilities for care at the time of consumption in order to meet the medical needs of the pregnant women and their fetus and prevent serious problems. 14 Appropriate counseling and opioid antagonistic drug treatments are among the suggested solutions to incarcerated pregnant women who are addicts. 53 One of the strengths of this study was using an extensive search strategy to find the relevant studies. However, like all studies it had some limitations. Most of the studies were conducted in the United States, which limits the generalizability of the findings. In addition, no information was obtained from middle-and low-income countries. In addition, the results of some studies did not follow the coherence and logical order, and this forced us to classify the results. In this review, only peer-reviewed articles were included, which could increase the risk of publication bias.

Conclusion
This study is the first systematic review of the needs of incarcerated pregnant women. Recognition of these needs and trying to meet them could improve the health of pregnancy in prison and improve its long-term and short-term results. In general, the needs of pregnant women in prison include the needs for adequate and quality prenatal care; education on pregnancy, childbirth and parenting, psychological and supportive counseling, nutrition, and substance abuse management. By recognizing these needs, accurate and appropriate programs can be designed and implemented for this vulnerable group. This systematic review showed evidence of a set of needs of incarcerated pregnant women that can be further investigated in future studies. In addition, this study could give insight to future researchers to explore other neglected needs of incarcerated pregnant women.